Polycystic ovarian syndrome (PCOS) is characterized by chronic anovulation, clinical and/or biochemical hyperandrogenism, which can be associated with altered insulin action. Symptoms usually begin around menarche, but onset after puberty may also occur as a result of environmental modifiers such as weight gain. The consequences of PCOS extend beyond the reproductive axis; there is a substantial risk for development of metabolic and cardiovascular abnormalities similar to the metabolic syndrome. Currently, the treatment is targeted to the patient's primary complaint such as hirsutism, restoration of regular menses or pregnancy. Pharmacological agents available for the treatment of hirsutism include androgen suppressors and peripheral androgen blockers. Recently, our understanding of the role of insulin resistance has led to the use of insulin-sensitizing medications as first-choice therapy. In conjunction with weight reduction and exercise, a pharmacologic reduction in insulin levels by either metformin or thiazolidinediones ameliorates both hyperinsulinemia and hyperandrogenism.
Pediatric nephrology has been established as an important specialty in the field of pediatrics over the past four decades. In 1976, the German society of Pediatric Nephrology (GPN) was founded (formerly known as APN) and annual spring conferences are an important event in this society. This years focus was congenital nephropathies, kidney and hormones, and dialysis and transplantation. A total of 133 original contributions were presented.
Pediatric HealthVol. 4, No. 1 EditorialFree AccessPediatric cancer survivorship: is our work nearly done or just beginning?Melissa M HudsonMelissa M HudsonSt Jude Children's Research Hospital, Department of Oncology, Cancer Survivorship Division, 62 Danny Thomas Place, Mailstop 735, Memphis, TN 38105, USA and University of Tennessee College of Medicine, Memphis, TN 38163, USA. Published Online:25 Jan 2010https://doi.org/10.2217/phe.09.62AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Owing to the significant advances achieved in pediatric cancer therapy over the last 50 years, long-term survival is a reality for 80% of children and adolescents diagnosed with cancer [1]. However, the success of curative therapy may be bittersweet for many who struggle with late-occurring chronic health issues resulting from the cancer or its therapy. Recent research indicates that approximately 75% of adults surviving pediatric cancer will develop at least one chronic health problem by 40 years of age, and 40% will experience a chronic condition that is severe, life-threatening or fatal [2,3]. Cancer-related late effects manifest as a variety of chronic medical and psychosocial disorders that can adversely impact overall health status of the long-term survivor [4–7]. Remarkably, for most outcomes studied, survivors exhibit impressive resilience, and serious life-threatening morbidity is limited to a minority of survivors. However, without intervention, chronic or subclinical changes that persist after cancer treatment can diminish survivors' quality of life and predispose them to early mortality [6,8].Over the years, recognition of late effects has prompted many therapeutic modifications of pediatric cancer care that have significantly reduced the incidence of acute life-threatening events. In most cases, late treatment sequelae can be anticipated based on therapeutic exposures, but their risk and manifestation in an individual patient is influenced by a myriad of cancer- and host-related factors [9]. Elucidation of factors influencing risk for specific outcomes related to the individual survivor (sex, race/ethnicity, age at diagnosis and attained age), sociodemographic status (education, household income and health insurance) and cancer history (diagnosis, treatment and time from diagnosis) has facilitated identification of groups at highest risk of morbidity [10]. Cancer patients may present with premorbid health conditions that affect their tolerance to therapy and enhance the risk of treatment toxicity [11–13]. Genetic or familial characteristics may confer additional risks for adverse outcomes [14–18]. Treatment modalities and intensity are determined by cancer-related factors including tumor location, histology and biology. Complications experienced during and after cancer therapy may add further morbidity. Cancer-related effects on psychosocial outcomes, including educational achievement, employment status and household income, influence a survivor's access to health insurance, healthcare and remedial services [5,19–21]. Survivors with cancer-related subclinical organ dysfunction may experience an earlier onset or accelerated progression of health conditions commonly associated with aging. Finally, lifestyle issues such as tobacco and alcohol use, sun exposure, dietary practices, and physical activity may augment the risk of specific health problems predisposed by cancer treatment. Appreciation of the multifactorial nature of cancer-related morbidity is important in devising the optimal plan for health screening and risk-reduction interventions for individual childhood cancer survivors [22].Despite the substantial research published concerning childhood cancer outcomes, significant knowledge deficits exist regarding important areas of long-term survivor health. In particular, we are limited in our understanding about the following issues of importance to adult survivors of pediatric malignancies: • How does cancer-related morbidity affect the natural course of organ senescence during adulthood?• What are the long-term implications of subclinical effects on cardiovascular, pulmonary, hepatic, musculoskeletal, dental and urinary tract function after contemporary risk-adapted treatment?• What are the late health outcomes impacting organ function, including neurocognitive, neurosensory, gonadal and sexual function?• How effective is contemporary radiation technology in reducing radiation-associated toxicity?• Does combined modality therapy enhance the risk of organ toxicity?• What are the long-term complications associated with surgical modalities such as amputation, limb-sparing or organ-preserving procedures and their impact on functional status and quality of life?• What are the late health outcomes resulting from more intensive interventions such as hematopoietic cell transplantation undertaken for children with relapsed and high-risk malignancies?• What lifestyle factors, such as smoking, obesity, and excessive alcohol intake, exacerbate the conditions mentioned above?• How do genetic factors influence the risk and manifestation of cancer-related toxicity?Identification of survivors at risk for adverse health outcomes permits interventions to detect, rehabilitate or prevent morbidity. Continued research is needed to facilitate timely identification of at-risk survivors and evaluate the multifactorial contribution of host, cancer, genetic, health behaviors and aging to the risk of adverse cancer-related health outcomes. This is a challenging endeavor because risk factors are constantly evolving with the introduction of new agents, modification of treatment approaches, and the aging of survivors. Therefore, health outcomes research objectives must adapt as cancer therapies evolve and new risk profiles for cancer-related morbidity are identified. To accomplish these objectives, research targeting well characterized clinical cohorts of adults surviving childhood cancer must be prioritized to improve understanding regarding host- and cancer-related risk factors predisposing to long-term cancer-related morbidity. Knowledge gained from these investigations offers the potential to improve quality of life for cancer survivors and their families, guide healthcare providers developing new treatment approaches and monitor long-term survivors, and facilitate approval of screening and remedial services by insurance companies and legislators.Without a doubt, our work in pediatric cancer survivorship is just beginning.Financial & competing interests disclosureThis work was supported in part by the Cancer Center Support (CORE) grants CA 21765 and CA 55727 from the National Cancer Institute and by the American Lebanese Syrian Associated Charities (ALSAC). The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Bibliography1 Jemal A, Siegel R, Ward E et al.: Cancer statistics, 2009. CA Cancer J. Clin.59(4),225–249 (2009).Crossref, Medline, Google Scholar2 Oeffinger KC, Mertens AC, Sklar CA et al.: Chronic health conditions in adult survivors of childhood cancer. N. Engl. J. Med.355(15),1572–1582 (2006).Crossref, Medline, CAS, Google Scholar3 Geenen MM, Cardous-Ubbink MC, Kremer LC et al.: Medical assessment of adverse health outcomes in long-term survivors of childhood cancer. JAMA297(24),2705–2715 (2007).Crossref, Medline, CAS, Google Scholar4 Diller L, Chow EJ, Gurney JG et al.: Chronic disease in the Childhood Cancer Survivor Study cohort: a review of published findings. J. Clin. Oncol.27(14),2339–2355 (2009).Crossref, Medline, Google Scholar5 Hudson MM, Mertens AC, Yasui Y et al.: Health status of adult long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. JAMA290(12),1583–1592 (2003).Crossref, Medline, CAS, Google Scholar6 Ness KK, Hudson MM, Ginsberg JP et al.: Physical performance limitations in the Childhood Cancer Survivor Study cohort. J. Clin. Oncol.27(14),2382–2389 (2009).Crossref, Medline, Google Scholar7 Zeltzer LK, Recklitis C, Buchbinder D et al.: Psychological status in childhood cancer survivors: a report from the Childhood Cancer Survivor Study. J. Clin. Oncol.27(14),2396–2404 (2009).Crossref, Medline, Google Scholar8 Armstrong GT, Liu Q, Yasui Y et al.: Late mortality among 5-year survivors of childhood cancer: a summary from the Childhood Cancer Survivor Study. J. Clin. Oncol.27(14),2328–2338 (2009).Crossref, Medline, CAS, Google Scholar9 Oeffinger KC, Hudson MM: Long-term complications following childhood and adolescent cancer: foundations for providing risk-based health care for survivors. CA Cancer J. Clin.54(4),208–236 (2004).Crossref, Medline, Google Scholar10 Hudson MM, Mulrooney DA, Bowers DC et al.: High-risk populations identified in Childhood Cancer Survivor Study investigations: implications for risk-based surveillance. J. Clin. Oncol.27(14),2405–2414 (2009).Crossref, Medline, Google Scholar11 Hyman SL, Gill DS, Shores EA et al.: Natural history of cognitive deficits and their relationship to MRI T2-hyperintensities in NF1. Neurology60(7),1139–1145 (2003).Crossref, Medline, CAS, Google Scholar12 Ross JA, Spector LG, Robison LL et al.: Epidemiology of leukemia in children with Down syndrome. Pediatr. Blood Cancer44(1),8–12 (2005).Crossref, Medline, Google Scholar13 Trobaugh-Lotrario AD, Smith AA, Odom LF: Vincristine neurotoxicity in the presence of hereditary neuropathy. Med. Pediatr. Oncol.40(1),39–43 (2003).Crossref, Medline, Google Scholar14 Malkin D, Friend SH, Li FP et al.: Germ-line mutations of the p53 tumor-suppressor gene in children and young adults with second malignant neoplasms. N. Engl. J. Med.336(10),734 (1997).Crossref, Medline, CAS, Google Scholar15 Ross JA, Oeffinger KC, Davies SM et al.: Genetic variation in the leptin receptor gene and obesity in survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study. J. Clin. Oncol.22(17),3558–3562 (2004).Crossref, Medline, CAS, Google Scholar16 Relling MV, Rubnitz JE, Rivera GK et al.: High incidence of secondary brain tumours after radiotherapy and antimetabolites. Lancet354(9172),34–39 (1999).Crossref, Medline, CAS, Google Scholar17 Relling MV, Yang W, Das S et al.: Pharmacogenetic risk factors for osteonecrosis of the hip among children with leukemia. J. Clin. Oncol.22(19),3930–3936 (2004).Crossref, Medline, Google Scholar18 Wong FL, Boice JD, Abramson DH et al.: Cancer incidence after retinoblastoma. Radiation dose and sarcoma risk. JAMA278(15),1262–1267 (1997).Crossref, Medline, CAS, Google Scholar19 Pui CH, Cheng C, Leung W et al.: Extended follow-up of long-term survivors of childhood acute lymphoblastic leukemia. N. Engl. J. Med.349(7),640–649 (2003).Crossref, Medline, Google Scholar20 Nathan PC, Greenberg ML, Ness KK et al.: Medical care in long-term survivors of childhood cancer: a report from the childhood cancer survivor study. J. Clin. Oncol.26(27),4401–4409 (2008).Crossref, Medline, Google Scholar21 Oeffinger KC, Mertens AC, Hudson MM et al.: Health care of young adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Ann. Fam. Med.2(1),61–70 (2004).Crossref, Medline, Google Scholar22 Hudson MM: Survivors of childhood cancer: coming of age. Hematol. Oncol. Clin. North Am.22(2),211–231, v–vi (2008).Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Vol. 4, No. 1 Follow us on social media for the latest updates Metrics Downloaded 288 times History Published online 25 January 2010 Published in print February 2010 Information© Future Medicine LtdFinancial & competing interests disclosureThis work was supported in part by the Cancer Center Support (CORE) grants CA 21765 and CA 55727 from the National Cancer Institute and by the American Lebanese Syrian Associated Charities (ALSAC). The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.PDF download
Sinusitis is one of the most common diseases presented to the primary care practioner. In this setting it is key to distinguish those children who have uncomplicated viral upper respiratory tract infection from those who have acute bacterial sinusitis. Sinusitis may be diagnosed based on the presence of persistent or severe respiratory symptoms or when a respiratory illness has a biphasic presentation. Radiographs or computed tomography scans are not usually needed to diagnose sinusitis in children. Well-designed randomized, controlled trials demonstrated the benefit of antibiotics compared to placebo. Antimicrobial therapy should be targeted against the three major pathogens responsible for sinusitis, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Amoxicillin or amoxicillin/clavulanate are the antibiotics of choice for children with acute bacterial sinusitis.
Evaluation of: Bundy DG, Strouse JJ, Casella JF, Miller MR: Burden of influenza-related hospitalizations among children with sickle cell disease. Pediatrics 125, 234–243 (2010). Children with sickle cell disease (SCD) are particularly vulnerable to invasive bacterial infections. Influenza virus infection multiplies the risk by destroying physical barriers to penetration by bacteria that inhabit the respiratory tract and by further impairing the function of polymorphonuclear leukocytes. Bundy et al. have quantitated the risk of hospitalization of children with SCD with discharge diagnoses including influenza. They accessed the Healthcare Cost and Utilization Project State Inpatient Databases for California, Florida, Maryland and New York, USA, to find the cases for the epidemic years 2003–2004 and 2004–2005 and calculated rates for children with SCD, cystic fibrosis or neither. They found that the rates for children with SCD were approximately two-times higher than for those with cystic fibrosis, and 56-ti...
Acute pancreatitis has a large medical and economic impact on healthcare for adults and children. The impact in childhood has become more significant because the diagnosis of acute pancreatitis has increased over the last 20 years. The incidence of acute pancreatitis has increased sixfold or more since the early 1990s to the present. The reasons for the increase are not clear. The most compelling data suggest that increased physician awareness is largely responsible for the increased diagnosis of acute pancreatitis in childhood. Physicians who care for children need to be aware that acute pancreatitis is more common in childhood than previously believed.
The addition of long-acting β2-agonists (LABAs) to inhaled corticosteroid for the treatment of asthma in children over 5 years of age is highly beneficial in the short term at improving lung function and day-to-day symptoms. Unfortunately, the effect wanes with time in some children. In addition, some children may still experience severe exacerbations while on LABAs. It is therefore important to ensure that these children are receiving adequate doses of inhaled corticosteroid before consideration be given to stopping LABA therapy. Further research is required in order to determine whether the rapid onset of action observed in formoterol therapy can be beneficially used in a combination single inhaler for both reliever and maintenance therapy.
Celiac disease (CD) is now recognized as one of the most common genetic diseases of humankind. Furthermore, and contrary to previous opinion that categorized CD as a primarily pediatric disorder, CD can occur at any age and can present with a wide range of clinical manifestations. Missed and delayed CD diagnoses are common for a number of reasons, one of which is a lack of CD awareness among primary healthcare clinicians. The purpose of this article is to increase clinicians' knowledge and awareness of CD.
Early-onset scoliosis is a diagnosis when a child is presenting with scoliosis before the age of 5 years. This excludes other causes of scoliosis (e.g., congenital, neuromuscular or syndromic). Twin studies and observations of familial aggregation reveal significant genetic contributions to idiopathic scoliosis. Radiographic criteria help in distinguishing the progressive curves from those that will resolve spontaneously. One must do a complete clinical evaluation to exclude other organ involvement especially congenital heart disease, inguinal hernia and hip dysplasia. MRI scans of the neural axis are mandatory in curves greater than 20° at presentation to rule out any occult lesions in the CNS. Minor nonprogressive curves can be managed with observation until growth is completed. Some curves may be managed with casting and bracing. There is increased risk of morbidity and mortality due to respiratory failure in untreated children with early-onset scoliosis who have progressive curves. Therefore, progressive curves must be addressed surgically. Surgical procedures continue to evolve and are primarily directed at correcting and maintaining the curve correction while simultaneously preserving spinal and trunk growth. A definitive spinal fusion is indicated once the thoracic spinal growth is nearing completion.
Although less common than hemophilia or von Willebrand disease, inherited rare bleeding disorders, comprising afibrinogenemia and deficiencies in factors II, V, VII, X, XI, XIII or V plus VIII combined, or in vitamin K-dependent coagulation factors, may lead to severe bleeding episodes such as recurrent hemarthroses and neonatal intracranial or gastrointestinal hemorrhage. Consanguinity significantly increases the risk of the occurrence of all rare bleeding disorders that are associated with an autosomal recessive pattern of inheritance. Each of the disorders is characterized by a wide interindividual variation in clinical phenotype and a large mutational spectrum with no clear correlation between the phenotype and genotype. Replacement therapy relies on specific molecules or concentrates (afibrinogenemia, factor VII, XI and XIII deficiencies), on a mixture of different concentrates that are otherwise known as a prothrombin complex, which contains factors II, VII, IX and X, or on fresh frozen plasma. International consensus guidelines for treatment modalities are progressing; however, guidelines for prophylaxis, especially in pediatric patients, are lacking.
Over the past two decades knowledge of and interest in autism has increased dramatically amongst both medical professionals and the wider public, and the relatively heterogeneous nature of the autism spectrum has become widely accepted. The expansion of the concept of the autism spectrum and the consequent rise in the number of people diagnosed with autism has led to controversy as to whether the true incidence of autism is on the increase or whether better diagnostic practice means that previously unidentified cases are no longer missed. Whereas autism is predominantly understood in dimensional terms today, the most authoritative definitions of autism and the diagnostic instruments used clinically and in research are still linked to a more categorical framework. Recently, there has been much interest in the early identification and diagnosis of autism, although the utility of universal early screening for autism spectrum disorders has not yet been demonstrated.
Hemophilia A and B, the congenital deficiencies of coagulation factors VIII and IX, are characterized by recurrent joint and muscle bleeding episodes and progressive musculoskeletal damage (hemophilic arthropathy). Primary prophylaxis – that is, the regular infusion of factor concentrates after the first hemarthrosis and/or before 2 years of age – is now recognized as the first-choice treatment for children with severe hemophilia. Preventing bleeding from an early age enables avoidance of the clinical impact of hemophilic arthropathy and the consequences regarding psychosocial development and quality of life for these children. Interestingly, recent data suggest a role for early prophylaxis in also preventing inhibitor development, the most serious complication of treatment in hemophilia. Secondary prophylaxis, initiated after 2 years of age or after two or more joint bleeds, aims to avoid (or delay) the progression of arthropathy. In addition, better outcomes and better quality of life have been reported with earlier treatment. This review summarizes the evidence, current clinical strategies and open issues regarding prophylxis in children with hemophilia.
Pediatric HealthVol. 4, No. 2 EditorialFree AccessSkepticism to vaccines: enough already?Philip RosenthalPhilip RosenthalDivision of Pediatric Gastroenterology, Hepatology & Nutrition, University of California, San Francisco, 500 Parnassus Avenue, Box 0136, MU 4-East, USA. Published Online:30 Mar 2010https://doi.org/10.2217/phe.10.6AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Many well-meaning parents are reluctant to have their children vaccinated against common and potentially fatal infections because of the countless myths that circulate regarding vaccines. For example, many believe that vaccines are not necessary for their children because the diseases that they protect against are no longer a threat. Other myths maintain that certain vaccines can overwhelm the immune system or cause serious health problems such as autism or sudden infant death syndrome. While studies have shown no evidence to substantiate any of these vaccine myths and learned societies and influential groups, such as the Institute of Medicine (Washington, DC, USA), have refuted any such associations, persistence of these myths contributes to a less than desirable level of immunity across the USA and other developed countries [1,2].Vaccines have a record of outstanding safety and efficacy. In the USA, as in most countries, vaccines are required to be performed with a very high standard of safety and are associated with a lower likelihood of risk than other medications that are routinely utilized in children. Part of this requirement is related to the use of vaccines in healthy individuals. Furthermore, vaccines are often universally recommended or mandated, making safety a very high priority. One example of the high standards applied to vaccines is the recent elimination of thimerosol (sodium ethylmercurithiosalicylate) as a preservative in childhood vaccines [3]. Thimerosol, an organomercury compound, which is 49% mercury by weight, has antiseptic and antifungal properties. Concerns based on extrapolations from the effects of methylmercury on the nervous system led to the removal of thimerosol from US childhood vaccines starting in 1999. Since then, it has been found that ethylmercury is cleared from the body and brain significantly faster than methylmercury, so the late-1990s risk assessments turned out to be overly conservative. However, because thimerosol contains mercury and there was concern that even the small amounts present in vaccines could result in mercury poisoning, manufacturers developed ways to make vaccines without thimerosol, even though no cases of mercury poisoning as the result of vaccination have ever been documented.'Community' or 'herd immunity' refers to the immunity of a population group or community. It is composed of a composite of immunity acquired both naturally from infection and through immunization. In order to prevent the spread of an infection to susceptible individuals, community immunity must approach 95%. Obviously, this figure varies with the transmissibility of a particular disease. Vaccine-preventable infections are often easily transmissible to other individuals depending on the population density, but immunization of the majority of individuals in the community can protect the few vulnerable persons in the community who are not vaccinated. This is one approach that is cited and utilized by skeptical parents of vaccinations, whose children benefit from the herd immunity afforded by other individuals who are immunized within society. However, when a community is composed of similar-minded parents who are skeptical of vaccines, outbreaks with often fatal or debilitating consequences ensue. One's health, to some extent, is dependent upon the actions of friends, neighbors and strangers within the community. Unfortunate examples of unvaccinated children developing significant morbidity and mortality from vaccine-preventable diseases include the 2008 Hemophilus influenzae type B outbreak in Minnesota, USA, the mumps outbreaks on the East Coast of the USA and more than two dozen measles outbreaks across the USA in 2008.Nationwide, the number of children who are exempt from school immunization requirements has grown by 50% since 1991 according to a recent New England Journal of Medicine article [4]. Children with nonmedical exemptions are at increased risk for acquiring and transmitting vaccine-preventable diseases. As a result of concerns raised regarding vaccines overwhelming the immune system, instead of refusing vaccines, some parents delay vaccine administration to their children. While the consequences of delayed vaccination as opposed to vaccine refusal are not well studied, it is known that the risks of vaccine-preventable diseases are not constant throughout childhood. In fact, young children are often at an increased risk.So what can be done to reverse this concerning trend? Pediatricians, family physicians and other healthcare providers play a critical role in parental decision making with regard to vaccination. Some physicians have discontinued or considered discontinuing relationships with families that refuse vaccines. The Academy of Pediatrics Bioethics Committee (IL, USA) advises against discontinuing care for families who decline vaccines. It is recommended that in addition to reviewing the evidence for the effectiveness and safety of vaccines in general, it is important to clearly explain to skeptical parents the risks and benefits that a particular vaccination poses to their child and others within the community. Language that is easy to understand should be utilized and care should be taken not to be critical, impatient or condescending. Utilizing information sheets provided by the CDC (vaccine information statements) that explain to vaccine recipients and their parents the benefits and risks of a particular vaccine may be particularly helpful. Vaccine information statements have been written to be easily understood, even by adults with a low literacy level, and they are available in 30 different languages. Other tactics that can aid in overcoming the parental skepticism of vaccines include outlining childcare and school mandates for immunizations, explaining the rationale for their enactment and why their particular child should be immunized. Another very effective method is to point out any recent disease outbreaks in their area to underscore the importance of immunization and how cracks in herd immunity can easily occur when there is a clustering of exemptions to immunization in a community.To help dispel myths, the impressive accomplishments attributable to vaccines over the past century should be reviewed with skeptical parents. The morbidity and mortality associated with vaccine-preventable diseases has declined dramatically, showing that vaccines really work. Physicians should highlight the various safety monitoring initiatives that help to ensure the safety of vaccines; these include strict US FDA licensure standards, the requirement of reporting adverse events through the Vaccine Adverse Events Reporting System (VAERS), in-depth investigation of adverse events through Clinical Immunization Safety Assessment centers, active surveillance through the Vaccine Safety Datalink project, and Institute of Medicine reviews of vaccine-related issues.Financial & competing interests disclosurePhilip Rosenthal is on the Speaker's Bureaus for Merck and GlaxoSmithKline – manufacturers of vaccines. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Bibliography1 Baker JP: Mercury, vaccines and autism: one controversy, three histories. Am. J. Public Health98,244–253 (2008).Crossref, Medline, Google Scholar2 DeStefano F: Vaccines and autism: evidence does not support a causal association. Clin. Pharmacol. Ther.82,756–759 (2007).Crossref, Medline, CAS, Google Scholar3 Ball LK, Ball R, Pratt RD: An assessment of thimerosal use in childhood vaccines. Pediatrics107,1147–1154 (2001).Crossref, Medline, CAS, Google Scholar4 Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N: Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N. Engl. J. Med.360,1981–1988 (2009).Crossref, Medline, CAS, Google ScholarFiguresReferencesRelatedDetailsCited ByPredicting vaccine hesitancy from area‐level indicators: A machine learning approach14 September 2021 | Health Economics, Vol. 183 Vol. 4, No. 2 Follow us on social media for the latest updates Metrics History Published online 30 March 2010 Published in print April 2010 Information© Future Medicine LtdFinancial & competing interests disclosurePhilip Rosenthal is on the Speaker's Bureaus for Merck and GlaxoSmithKline – manufacturers of vaccines. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.PDF download
Aripiprazole was recently US FDA-approved to treat irritability in children and adolescents with autistic disorder aged 6-17 years. There are currently only two psychotropics approved by the FDA to treat irritability in the autistic population. This drug profile will discuss available studies of aripiprazole in individuals with pervasive developmental disorders, two of which led to its recent FDA approval. We will discuss the efficacy, as well as the safety and tolerability of the drug documented in these studies. In addition, the chemistry, pharmacokinetics, metabolism and mechanism of action of aripiprazole will be reviewed.
Pediatric HealthVol. 4, No. 3 EditorialFree AccessPneumocystis pneumonia in HIV-infected children: recent advances and future hurdlesHeather J ZarHeather J ZarDepartment of Paediatrics & Child Health, 5th floor ICH Building, Red Cross War Memorial Children's Hospital, University of Cape Town, 7700, South Africa. Published Online:7 Jun 2010https://doi.org/10.2217/phe.10.25AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Much progress has been made in the understanding of the epidemiology, clinical manifestations, prevention and treatment of pneumocystis since the organism Pneumocystis jirovecii was first described 100 years ago. Nevertheless, pneumocystis pneumonia (PCP) remains one of the most important and serious opportunistic infections in HIV-infected children. Pneumocystis infection is ubiquitous in children but pneumonia is unusual; marked immunosuppression is the essential factor that allows PCP to develop. PCP is associated with severe, rapidly progressive pneumonia in HIV-infected children with a case fatality rate of approximately 50% despite timely use of antibiotics, corticosteroids and supportive interventions.Early use of pneumocystis prophylaxis – mainly cotrimoxazole (trimethoprim-sulphamethoxazole [TMP-SMX]) – from 6 weeks of age in HIV-exposed infants has substantially reduced the incidence of PCP. In addition, timely use of highly active antiretroviral therapy (HAART) as soon as HIV is diagnosed has reduced the incidence of pediatric PCP. Implementation of preventative programs for mother-to-child HIV transmission has successfully reduced the incidence of pediatric HIV and the number of children susceptible to developing PCP. Recognition of the importance of this infection in HIV-infected children and of the efficacy of preventative interventions has led to global guidelines for prophylaxis and for early use of HAART [1].However, implementation or access to such interventions has been limited in low- or middle-income countries especially in Sub-Saharan Africa, where more than 90% of HIVinfected children reside. Even in countries with a national program for pediatric HIV, operational and logistical issues remain a challenge to widespread implementation of prophylaxis and HAART. For example, a recent South African study of HIV-infected children admitted with severe pneumonia reported that PCP remained a common cause of severe pneumonia and mortality even in the presence of an established, free public antiretroviral program, highlighting the difficulties in implementing preventative strategies [2]. Thus, PCP remains an important cause of severe and fatal pneumonia in HIV-infected children globally. PCP has been reported to cause 29–67% of respiratory-related deaths among African HIV-infected children, with in-hospital case-fatality rates ranging from 20 to 63%.In addition, HIV-exposed but uninfected children have been identified as being at higher risk for PCP than HIV-unexposed infants [2,3]. Possible reasons for this include poor protection from maternal antibodies, concomitant malnutrition, a defect in innate immunity or increased exposure to infection owing to a HIV-infected mother or other household member. Further understanding of the risk of PCP and the role of pneumocystis prophylaxis in HIV-exposed infants is needed.Diagnosis of PCP can be challenging, as clinical signs and symptoms are nonspecific. Definitive diagnosis has been hampered by the inability to reliably perform in vitro culture. However, progress in the use of molecular methods has enabled greater understanding of colonization, infection and disease owing to P. jirovecii. The mitochondrial genome has been sequenced through the Pneumocystis genome project [101]. The detection of mutations in the gene coding for the enzyme dihydropteroate synthase (DHPS) has made detection of TMP-SMX resistance possible. Molecular techniques have demonstrated a high prevalence of colonization in mammals. Colonization has recently been described in adults with chronic lung disease, with implications for spread of infection to children [4,5].Standard methods for identification include silver methenamine staining or immunofluorescence (which has greater reliability than silver staining) on a sample from the lower respiratory tract. Using these methods, the yield is highest from bronchoalveolar lavage fluid or induced sputum, with a variable and poor yield from an upper respiratory tract specimen such as a nasopharyngeal aspirate. However, molecular methods performed on upper airway secretions (oropharyngeal or nasal aspirate) have reported promising results in adult studies. For the future, improved, cost-effective methods for diagnosis by molecular techniques on samples that can be obtained noninvasively in children should be a priority.The importance of polymicrobial infections in children with PCP has recently been recognized with bacterial–pneumocystis, mycobacterial–pneumocystis or viral–pneumocystis infections being reported [2,3]. Cytomegalovirus virus (CMV)-associated pneumonia has been frequently reported as a coinfection with PCP and associated with a poor outcome. However, CMV pneumonia may be a marker of severe immunosuppression rather than directly causing death. Mortality increases exponentially with the number of pathogens [3].Empiric treatment should be given to any HIV-exposed or -infected infant, with a rapidly progressive hypoxic pneumonia, especially if they are not taking prophylaxis. First-line recommended treatment is TMP-SMX [6,7]. Sulfur drugs interfere with folate synthesis by competitively inhibiting the DHPS enzyme. Intravenous therapy (TMP 15–20 mg/kg/day in three or four divided doses) for 21 days is recommended [7]. Oral therapy may be used in mild or moderate disease or once clinical improvement has occurred. Lower levels of TMP or SMX may occur with standard oral therapy compared with the intravenous equivalent, thus higher doses of oral TMP-SMX may be needed if used as initial therapy [8]. Clinical improvement is often slow, taking 5–7 days. Increasingly, DHPS mutants have emerged in association with exposure to TMP-SMX. However, no consistent association between DHPS mutants and clinical disease or treatment failure has been shown. Failure to respond to treatment after 5–7 days or the presence of a severe adverse reaction requires alternative therapy, such as pentamidine (4 mg/kg/day), atovaquone, dapsone with trimethoprim, trimetrexate glucuronate with leucovorin or clindamycin with primaquine; most of these have not been well evaluated in children [7].Pneumocystis pneumonia is associated with an exuberant inflammatory response that promotes lung injury. The use of corticosteroids has been shown to decrease oxygen dependency and mortality in HIV-infected adults with moderate-to-severe PCP when used within 72 h of treatment. No large, randomized controlled trials have been performed in children, but studies suggest prednisone may be effective at a dose of approximately 1 mg/kg for 5–7 days, followed by a tapering dose over the next 7–12 days. Concern regarding the potential for worsening of concomitant CMV disease with corticosteroid use has been raised; concomitant CMV-associated pneumonia or viremia should be treated with an appropriate antiviral drug.Effective preventive strategies for PCP include TMP-SMX and HAART. Prophylaxis reduced overall mortality and hospitalizations in HIV-infected African children older than 1 year of age with variable CD4 counts enrolled in a randomized controlled trial comparing TMPSMX with placebo [9]. TMP-SMX may also confer protection against bacterial infections in HIV-infected children living in settings with a high bacterial burden, although this has not been well studied. The optimal TMP-SMX dosing regime has not been well studied in children, with guidelines recommending either daily or intermittent therapy [1,7].Current WHO recommendations are for prophylaxis for all HIV-infected infants under 1 year of age, irrespective of CD4 cell count or clinical stage, to children aged 1–5 years at WHO clinical stage 2–4 or CD4 cell count of less than 25% and to children older than 5 years of age with a CD4 count of less than 350 cells per mm3 or clinical stage 2–4 [1]. Similarly, the CDC, NIH and the American Academy of Pediatrics recommend prophylaxis for all infants under 1 year of age, regardless of CD4 count or clinical stage [7]. For children aged 1–5 years prophylaxis should be administered if their CD4 count is less than 500 cells per mm3 (or less than 15%) and for children older than 6 years if their CD4 count is less than 200 cells per mm3 (or less than 15%) [7]. Prophylaxis in infants should begin at 4–6 weeks of age and should be administered once daily. For children unable to take CTX, atovaquone or dapsone may be used. Data from high-income countries indicate that TMP-SMX may be safely discontinued in children older than 2 years when sustained immune reconstitution has occurred, as measured by CD4 recovery in response to HAART [7]. However, the applicability of this to areas of high bacterial burden remains untested. Furthermore, data to guide the use and duration of prophylaxis in HIV-exposed uninfected infants are needed.For the future, the role of HIV exposure in determining risk, better understanding of the epidemiology and transmission of pneumocystis, improved diagnostic methods for PCP and copathogens, the significance of DHPS mutations and improved management strategies in children remain important challenges. For now, more widespread, global implementation of available, effective strategies for PCP prevention and treatment in HIV-infected children is needed.Financial & competing interests disclosureHeather J Zar has received research funding from the Medical Research Council and the National Research Foundation, South Africa, for pneumocystis research. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Papers of special note have been highlighted as: • of interest •• of considerable interestBibliography1 WHO: Guidelines for cotrimoxazole prophylaxis for HIV-related infections among children, adolescents and adults in resource-limited settings. Recommendations for a public health approach. WHO, Switzerland (2006).Google Scholar2 Morrow BM, Hsaio NY, Zampoli M, Whitelaw A, Zar HJ: Pneumocystis pneumonia in South African children infected with and without human immunodeficiency virus in the era of highly active antiretroviral therapy. Pediatr. Infect. Dis. J. DOI: 10.1097/INF.0b013e3181ce871e (2010) (Epub ahead of print).Medline, Google Scholar3 McNally LM, Jeena PM, Gajee K et al.: Effect of age, polymicrobial disease, and maternal HIV status on treatmen response and cause of severe pneumonia in South African children: a prospective descriptive study. Lancet369,1440–1451 (2007).Crossref, Medline, CAS, Google Scholar4 Calderon EJ: Epidemiology of pneumocystis infection in humans. J. Med. Mycol.19,270–275 (2009).Crossref, Google Scholar5 Catherinot E, Lanternier F, Bougnoux ME, Lecuit M, Couderc LJ, Lortholary O: Pneumocystis jirovecii pneumonia. Infect. Dis. Clin. North Am.24(1),107–138 (2010).Crossref, Medline, Google Scholar6 Pyrgos V, Shoham S, Roilides E, Walsh TJ: Pneumocystis pneumonia in children. Paediatr. Respir. Rev.10(4),192–198 (2009).• Recent review on the epidemiological, clinical and management aspects of pneumocystis pneumonia (PCP) in children.Crossref, Medline, Google Scholar7 Mofenson LM, Brady MT, Danner SP et al.; CDC; NIH; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics: Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm. Rep.58(RR-11),1–166 (2009).•• Extensive evidence-based review of strategies for the prevention and treatment of PCP in children.Medline, Google Scholar8 Zar HJ, Langdon G, Apolles P, Eley B, Hussey G, Smith P: Oral trimethoprim-sulphamethoxazole levels in stable HIV-infected children. S. Afr. Med. J.96,627–629 (2006).Medline, CAS, Google Scholar9 Chintu C, Bhat GJ, Walker AS et al.: Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double-blind randomised placebo-controlled trial. Lancet364,1865–1871 (2004).• The only published randomized controlled trial of cotrimoxazole for PCP prophylaxis in HIV-infected children.Crossref, Medline, CAS, Google Scholar101 Pneumocystis genome project http://pgb.cchmc.orgGoogle ScholarFiguresReferencesRelatedDetails Vol. 4, No. 3 Follow us on social media for the latest updates Metrics Downloaded 521 times History Published online 7 June 2010 Published in print June 2010 Information© Future Medicine LtdFinancial & competing interests disclosureHeather J Zar has received research funding from the Medical Research Council and the National Research Foundation, South Africa, for pneumocystis research. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.PDF download
Asthma represents one of the most common chronic conditions affecting children. Effective therapies exist, but some children continue to have treatment-resistant asthma. Management remains a significant challenge and evidence for the treatment of asthma at the severe end of the spectrum is lacking. However, a structured approach to assessment and management can be used to improve patient outcomes. For the minority in whom symptoms persist, further investigations, alternative anti-inflammatory drugs or more novel therapies, such as anti-IgE, may need to be considered and these are best carried out by a specialist pediatric pulmonologist. Further developments in the use of noninvasive biomarkers to help individualize treatment will be helpful in the future treatment of severe asthma.
As one of the common childhood infections, urinary tract infections (UTIs) take up an important part of a pediatrician’s daily routine practice. Not only can UTIs lead to life-threatining complications in infants, but also to renal scarring and related complications in all age groups. In order to avoid morbidity, it is suggested that treatment should be started as soon as a UTI is recognized, but because urine cultures (the gold-standard for the diagnosis of UTI) take 24–48 h to process, initial treatment is started empirically. At this point, knowledge of the pathogens causing the UTI and local antibiotic sensitivity patterns are needed to ensure appropriate treatment. With this purpose, studies were conducted all over the world and high levels of resistance to ampicillin, cephalexin and trimethoprim-sulphametoxazole were commonly reported. The prevalence of antibiotic resistance of uropathogens in complicated and recurrent UTIs was found to be even higher than that in first, uncomplicated UTIs. Multidrug resistance in pediatric UTIs has been determined to be 3.1–7.1% and the most commonly reported coresistance is to ampicillin and trimethoprim-sulphametoxazole. Cefuroxime, cefixime and cefdinir in addition to co-amoxilav are suggested as first-line oral antibiotics, whereas aminoglycosides are suggested for use in the parenteral treatment of UTIs. With low resistance rates, nitrofurantoin is recommended for the treatment of cystitis and prophylaxis.
Evaluation of: Davila-Perez R, Bracho-Blanchet E, Tovilla-Mercado JM et al.: Unnecessary gastric decompression in distal elective bowel anastomoses in children: a randomized study. World J. Surg. 34(5), 947–953 (2010). Although the use of nasogastric decompression after intestinal surgery has been a common practice for decades, there has not been a prospective randomized trial that supports its purported benefits in children. Davila-Perez and colleagues undertook a scientific approach to the use of nasogastric decompression in children undergoing intestinal anastomoses to determine if clinical benefits could be identified. They randomized 60 pediatric patients undergoing intestinal anastomoses to either undergo nasogastric decompression for 5 days or to not have gastric decompression during the postoperative period. The study was designed as an equivalence study, with a goal to demonstrate that there was equivalence between the treatment arms. The results, with the use of sophisticated statistics, supported the authors conclusions that there is no difference in the postoperative course of pediatric patients that undergo gastric decompression when compared with those not undergoing gastric decompression, and that routine use of gastric decompression should be eliminated.
Pediatric HealthVol. 4, No. 4 EditorialFree AccessTrichophyton tonsurans: the need for enhanced infection control measures in the pediatric populationSusan M Abdel-RahmanSusan M Abdel-RahmanDivision of Clinical Pharmacology & Medical Toxicology, The Children's Mercy Hospitals & Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA and Department of Pediatrics, University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA. Published Online:24 Aug 2010https://doi.org/10.2217/phe.10.42AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Keywords: epidemicpublic healthsurveillancetinea capitisPrior to the 1950s, tinea capitis was regarded as a public health problem significant enough to merit active surveillance and aggressive management in the USA. Proactive infection control measures included school-based screenings of children carried out by public health nurses; reactive containment efforts included the detainment or debarment of immigrants at Ellis Island (NY, USA) if they were discovered to manifest symptoms of tinea capitis; and treatment that would be considered objectionable by today's standards included irradiation of the scalp or mechanical epilation followed by the application of compounds such as mercury, sulfur and tar. In 1958, 20 years after its initial discovery, griseofulvin was evaluated against experimental and human dermatophytoses. It subsequently became the first orally administered chemotherapeutic agent available for the treatment of dermatophyte infections that were recalcitrant to topical therapy.Griseofulvin's introduction led to a marked decline in the prevalence of Microsporum-associated scalp infections. It did not take long, however, for clinical investigators to recognize that Trichophyton tonsurans rapidly began occupying the niche vacated by Microsporum audouinii. Reports of this shift in epidemiology peppered the medical literature, yet they failed to gain traction and did little to influence coordinated infection control efforts for tinea capitis. With its success, griseofulvin appeared to usher in an era of complacency in population-based surveillance and management of tinea capitis; however, the diminution in active surveillance was likely multifactorial. A major challenge to screening lay with the fact that this endothrix pathogen does not fluoresce under UV light. Thus, the Wood's lamp was no longer a viable tool for rapidly screening large populations. Additionally, the symptoms associated with T. tonsurans tinea capitis were less pronounced than those caused by Microsporum spp., which may have resulted in protracted intervals between infection and diagnosis. Finally, the effort to gain attention for T. tonsurans may have been hampered by the fact that the organism is often overshadowed by Trichophyton rubrum. Surveys that report the relative prevalence of dermatophyte species as measured by specimens received in community- or academic-based microbiology laboratories, largely underestimate the prevalence of the pediatric pathogen T. tonsurans much in the same way that reports from a pediatric institution would underestimate the prevalence of the common adult pathogen, T. rubrum.Despite limited efforts at prospective surveillance, the clinical presentation of T. tonsurans tinea capitis became well characterized and the demography well documented (i.e., school-aged, African–American children). It was also discovered that children could harbor the fungus without any clinical indicators of disease, suggesting the presence of a carrier state. However, reports that attempted to address infection rates were often conducted in self-referred or selected populations, thereby offering only sparse estimates of prevalence for symptomatic disease and meaningless estimates for asymptomatic carriage. Recently, studies which have undertaken more rigorous screening approaches in unselected populations reveal that an estimated one in eight school-aged African–American children residing in urban US settings are infected (symptomatic or asymptomatic) and as many as one in three preschool-aged children of the same demographic constitution harbor T. tonsurans on their scalp [1–3]. These rates surpass many common childhood infections and are on par with dermatophyte infection rates for other endemic species in developing countries.These striking infection rates would be less concerning, and in fact might not exist, if the currently available treatment strategies effectively eradicated T. tonsurans. However, griseofulvin's efficacy in clinical trials does not appear to reflect its effectiveness in clinical practice. While cited response rates approach 60–80%, the application of molecular fingerprinting and serial scalp sampling in clinical practice suggests that less than 25% of children may sustain a culture negative status after a single 6–8-week course of therapy [4]. Such findings would not be uncovered in clinical trials that perform single-point estimates of mycological cure or those with limited longitudinal evaluations restricted to speciation alone. Importantly, it is unlikely that these clinical treatment failures reflect an innate resistance of T. tonsurans to griseofulvin [5], and more likely that they represent inadequate drug regimens in a population with a high fungal burden.The inadequacy of griseofulvin for the management of tinea capitis has not escaped notice by agencies within the US Department of Health and Human Services. The Director of the NIH cited griseofulvin among the top drugs for which "pediatric studies are most urgently needed" based on their "frequency of use in the pediatric population, severity of the condition being treated and potential for providing a health benefit" [6]. In follow-up, the US FDA issued written requests to several pharmaceutical companies for additional studies of griseofulvin under the Best Pharmaceuticals For Children Act. Unfortunately, no new data on which to base dosing changes in griseofulvin were generated and only one additional drug has received FDA approval for tinea capitis in the past 50 years.Hindering progress in containing this infection has been the limited amount of basic investigative biological research being conducted on the dermatophytes, including T. tonsurans. Over the past two decades, the NIH has funded a mere nine grants dealing with tinea capitis (half of which were intended to examine the outcomes of children treated decades earlier with irradiation) and only two grants containing the keyword T. tonsurans[101]. In addition, it took years of lobbying and white papers before dermatophytes were approved for genome sequencing and, although recently finished, T. tonsurans was sequenced with only low coverage leaving numerous sections of the genome incomplete.The public sector appropriations for research in the area of T. tonsurans tinea capitis are in stark contrast to private sector investments for other dermatophyte infections. In a single year, the innovator of an antifungal labeled for dermatophytoses was reported to have spent US$100 million in advertising. Notably, these advertising campaigns emphasized the drugs indication for onychomycosis and not tinea capitis. While the following assertion may be solely the impression of this author, it would appear that drug development and marketing is far more aggressive for the treatment of dermatophyte infections that predominate in the middle-aged, middle-class majority (e.g., onychomycosis and athletes foot) while infections of the young, socioeconomically-disadvantaged minority are relatively neglected. Given the sizable proportion of children that demonstrate persistent scalp infections, and the growing data that suggest that chronic dermatophytoses can exacerbate seemingly unrelated comorbidities (e.g., asthma, urticaria and allergic rhinitis), it is unclear why T. tonsurans tinea capitis is not more actively advocated for and/or pursued by the public, the healthcare community, the government and the private sector.Importantly, the brunt of the impact generated by T. tonsurans is no longer restricted to countries within North American borders. T. tonsurans infections have been on the rise in Europe for over a decade and have become a serious epidemic among combat sport participants in Asia and the Middle East. In fact, T. tonsurans infections have become such an overwhelming problem in Japan that martial arts officials are quoted as saying "…if they leave this infection unchecked it will ruin Japanese judo" and the Japan Judo Federation is calling for active screening of all participant athletes. As a result, some sports organizations find themselves screening and recommending treatment for all culture positive athletes irrespective of whether they appear symptomatic [7].A notable scientific observation, likely arising from the high fungal burden, is the significant degree of genetic variability that can be observed within T. tonsurans. To date, 65 distinct, stable, genetic strain types have been characterized across North America, Europe, Asia and Australia [8]. As many as two-thirds of the reported strain types can be represented among isolates recovered from a given city (n = 43 in Kansas City, MO, USA). Intriguingly, the strain types in greatest abundance in North America do not reflect the clonal strain type that, at present, appears to predominate among combat sport participants in the Middle East and Japan [9–11]. Ongoing surveillance, coupled with molecular analyses and aggressive management, will reveal whether the epidemic outbreaks experienced in Japan and similar countries can be successfully eradicated or whether they will transition into endemic disease as is now observed in North America.Perhaps the lessons learned from our Japanese colleagues attempting to prevent the destruction of their national pastimes (judo and sumo), will serve to drive more aggressive infection control efforts in the countries where T.tonsurans is endemic. Conceivably, new therapeutic targets may even emerge with the availability of the completed fungal genome sequence. For countries like the USA, however, it may be too late to consider treatment alternatives in isolation. Can a child who is effectively treated with a newer/better antifungal be expected to remain free of infection when returned to an environment where one in every three children carry the pathogen? Arguably, the answer is no. Instead, thoughtfully constructed, empirically driven, infection control strategies that consider prevention, treatment, environmental remediation and prospective surveillance will likely be required before we can effectively gain control of this infection.Financial & competing interests disclosureThe author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.Bibliography1 Williams JV, Honig PJ, McGinley KJ, Leyden JJ: Semiquantitative study of tinea capitis and the asymptomatic carrier state in inner city school children. Pediatrics96,265–267 (1995).Medline CASGoogle Scholar2 Abdel-Rahman SM, Farrand N, Schuenemann E et al.: Prevalence of infections with Trichophyton tonsurans in school children (the CAPITIS study). Pediatrics125,966–973 (2010).MedlineGoogle Scholar3 Abdel-Rahman SM, Simon S, Wright KJ, Ndjountche L, Gaedigk A: Tracking Trichophyton tonsurans through a large urban childcare center: defining infection prevalence and transmission patterns by molecular stain typing. Pediatrics118,2365–2373 (2006).MedlineGoogle Scholar4 Abdel-Rahman SM, Wright KJ, Navarre H: Griseofulvin has only a modest impact on eradicating carriage of Trichophyton tonsurans. J. Pediatr. Pharmacol. Ther.14,94–99 (2009).MedlineGoogle Scholar5 Gupta AK, Williams JV, Zaman M, Singh J: In vitro pharmacodynamic characteristics of griseofulvin against dermatophyte isolates of Trichophyton tonsurans from tinea capitis patients. Med. Mycol.11,1–6 (2009).Google Scholar6 Zerhouni EA: Preliminary list of drugs for which pediatric studies are needed. Federal Register69,47161–47162 (2004).Google Scholar7 Hirose N, Suganami M, Ogawa YS, Hiruma M, Ogawa H: Screening examination and treatment of Trichophyton tonsurans infection in judo athletes affiliated with the University Judo Federation of Tokyo. Mycoses (2009) (Epub ahead of print).Google Scholar8 Abdel-Rahman SM, Sugita T, Gonzalez-Gonzalez G et al.: Divergence among an international population of Trichophyton tonsurans isolates. Mycopathologia169,1–13 (2010).MedlineGoogle Scholar9 Sugita T, Shiraki Y, Hiruma M: Genotype analysis of the variable internal repeat region in the rRNA gene of Trichophyton tonsurans isolated from Japanese Judo practitioners. Microbiol. Immunol.50,57–60 (2006).Medline CASGoogle Scholar10 Mochizuki T, Kawasaki M, Tanabe H, Anzawa K, Ishizaki H, Choi JS: Molecular epidemiology of Trichophyton tonsurans isolated in Japan using RFLP analysis of non-transcribed spacer regions of ribosomal RNA genes. Jpn. J. Infect. Dis.60,188–192 (2007).Medline CASGoogle Scholar11 Ilkit M, Saracli MA, Kurdak H et al.: Clonal outbreak of Trichophyton tonsurans tinea capitis gladiatorum among wrestlers in Adana, Turkey. Med. Mycol.48,480–485 (2010).MedlineGoogle Scholar101 NIH Research Portfolio Online Reporting Tools (RePORT) http://projectreporter.nih.govGoogle ScholarFiguresReferencesRelatedDetailsCited ByDevelopment and Application of a High-Throughput Screening Method to Evaluate Antifungal Activity against Trichophyton tonsuransSLAS Discovery, Vol. 20, No. 9Trichophyton tonsurans scalp carriage among wrestlers in a national competition in Turkey7 April 2011 | Mycopathologia, Vol. 172, No. 3 Vol. 4, No. 4 Metrics History Published online 24 August 2010 Published in print August 2010 Information©Future Medicine LtdKeywordsepidemicpublic healthsurveillancetinea capitisFinancial & competing interests disclosureThe author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download
The purpose of this review is to advocate the use of ultrasonography (US) techniques in the work-up of children after a urinary tract infection (UTI). Currently, two major approaches are recognized. The first approach recommends looking for vesicoureteral reflux (VUR) in all children following a UTI. New techniques have been developed where, in the majority of cases, x-ray voiding cystourethrography (VCUG) is first substituted with radionuclide voiding cystography, and finally with echo-enhanced voiding urosonography, and this presented a significant improvement in diminishing the radiation burden on patients; yet there remained the drawback that catheterization is still necessary with all of these techniques. The introduction of catheter-free procedures would be a 'final solution', but these are yet to be validated. The second approach recommends screening for scars (mostly using a dimercaptosuccinic acid renal scan), while cystographies (preferably VCUG) are only performed in cases in which renal scarring has been confirmed. It was demonstrated that a dimercaptosuccinic acid renal scan can be safely and efficiently replaced by US, while voiding urosonography can substitute VCUG in children with confirmed scars in whom one believes VUR should be sought. From here on, catheter-free US techniques for VUR detection, although promising a 'final solution', still remain to be validated. In conclusion, regardless of which approach one believes is more appropriate in the management of children following a UTI, it is obvious that both protocols can be sufficiently fulfilled by the use of US techniques. At this time, more studies are needed to properly validate the latest noninvasive (catheter-free) US techniques for VUR detection.
